Delavan Health Services
905 E Geneva St, Delavan, WI 53115 · Walworth County · 50 certified beds · avg 42 residents/day · certified since Nov 1, 1982
Part of chain: NORTH SHORE HEALTHCARE (59 facilities, chain avg rating 2.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jun 15, 2022 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 13, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (12)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 19, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 19, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jun 15, 2022 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jun 15, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 15, 2022 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Jun 15, 2022 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 15, 2022 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jun 15, 2022 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jun 15, 2022 | C · Minimal risk, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (3 → 1).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 7 | 1 | G ▲ |
| 2023 | 3 | 0 | D |
| 2024 | 2 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.23 | 4.29 | 3.95 | bottom 13% in Wisconsin; bottom 23% in the U.S. |
| Registered Nurse hours | 1.16 | 1.01 | 0.69 | top 30% in Wisconsin; top 11% in the U.S. |
| Weekend total nurse staffing | 2.90 | 3.84 | 3.50 | bottom 15% in Wisconsin; bottom 26% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.00 | 0.68 | 0.48 | top 14% in Wisconsin; top 6% in the U.S. |
| Total nursing staff turnover (%) | 34.2 | 46.9 | 45.8 | top 16% in Wisconsin; top 22% in the U.S. |
| RN turnover (%) | 33.3 | 39.7 | 42.9 | top 40% in Wisconsin; top 33% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.21, RN 1.15, weekend 2.88. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Mills, David | Individual | 5% or Greater Indirect Ownership Interest | 20% | 06/29/2017 |
| NSHF Operations LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 07/24/2017 |
| Baumann, Troy | Individual | Corporate Director | NOT APPLICABLE | 06/29/2017 |
| Baumann, Troy | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2017 |
| Baumann, Troy | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2017 |
| Belongia, Christina | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2019 |
| Belongia, Christina | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2019 |
| Canda, Alex | Individual | ADP of the SNF | NOT APPLICABLE | 02/01/2023 |
| Cibc Bank USA | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 12/31/2024 |
| Cibc Bank USA | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/31/2024 |
| Cliftonlarsonallen LLP | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/22/2018 |
| Cliftonlarsonallen LLP | Organization | ADP of the SNF | NOT APPLICABLE | 04/15/2025 |
| Continuum Therapy Partners LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| Continuum Therapy Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/15/2025 |
| Gee, Darren | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/30/2021 |
| Gee, Darren | Individual | ADP of the SNF | NOT APPLICABLE | 11/30/2021 |
| Greer, Lauren | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/29/2023 |
| Greer, Lauren | Individual | ADP of the SNF | NOT APPLICABLE | 11/29/2023 |
| Hoehn, Jeffrey | Individual | Corporate Director | NOT APPLICABLE | 06/29/2017 |
| Hoehn, Jeffrey | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Williams Bay Health Services | 5.6 mi | Williams Bay, WI | ★☆☆☆☆ | 1/5 | |
| Holton Manor | 5.8 mi | Elkhorn, WI | ★★☆☆☆ | 2/5 | |
| Lakeland Health Care Ctr | 6.1 mi | Elkhorn, WI | ★★★☆☆ | 2/5 | abuse |
| Geneva Lake Manor | 11.0 mi | Lake Geneva, WI | ★☆☆☆☆ | 1/5 | |
| Golden Years of Lake Geneva | 12.0 mi | Lake Geneva, WI | ★★★★☆ | 5/5 | |
| Alden Meadow Park HCC | 12.7 mi | Clinton, WI | ★★★☆☆ | 3/5 | |
| Mercy Harvard Hospital Care Center | 14.8 mi | Harvard, IL | ★★★★★ | 5/5 | |
| East Troy Manor | 15.6 mi | East Troy, WI | ★★☆☆☆ | 2/5 | |
| Oak Park Place of Janesville | 18.4 mi | Janesville, WI | ★★☆☆☆ | 2/5 | |
| Lindengrove Mukwonago | 18.6 mi | Mukwonago, WI | ★★☆☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 525324.